Date: Fri, 19 May 1995 13:14:25 +0500 From: ghmcleaf{CONTRACTOR/ASPEN/ghmcleaf}%NAC-GATEWAY.ASPEN@ace.aspensys.com Subject: CDC Nat. AIDS Hotline Train. Bull. #140 CENTERS FOR DISEASE CONTROL AND PREVENTION HIV/AIDS PREVENTION CDC NATIONAL AIDS HOTLINE TRAINING BULLETIN ................................................................. May 1, 1995 #140 These are answers from the Centers for Disease Control and Prevention (CDC) to questions from the CDC National AIDS Hotline concerning the 1995 Revised Guidelines for Prophylaxis Against Pneumocystis carinii pneumonia for Children Infected with or Perinatally Exposed to Human Immunodeficiency Virus as published in the MMWR April 28, 1995 (Vol.44, No. RR-4). 1. How do the revised guidelines for PCP prophylaxis for children differ from the previous ones? The two most important differences are: a) According to the revised guidelines, prophylaxis should be started for all HIV-exposed children at 4-6 weeks of age. Prophylaxis should be stopped for children found not to be infected with HIV, but continued through the first year of life for all children who are HIV infected or whose infection status is still unknown. Under the previous guidelines, prophylaxis was started for HIV-exposed children (i.e., children born to HIV-infected mothers) when the child's CD4+ cell count fell below a certain level. B) The age-related CD4+ cell count and percentage levels recommended for prophylaxis for children r1 year old have been slightly modified. 2. Why were the guidelines revised? The previous guidelines were reevaluated because AIDS surveillance has not demonstrated a decline in the incidence of PCP in infants. Research has shown that the most important reason why the incidence of PCP has not declined is that many HIV-infected children are developing PCP because they have not been identified early enough to start prophylaxis. Research has also shown that CD4+ cell counts may not be useful in determining the need for prophylaxis among infants <1 year old. Many infants with PCP have CD4+ cell counts higher than the level previously recommended for starting prophylaxis and the CD4+ cell counts of many infants with PCP may drop rapidly before they develop PCP. Newer data on CD4+ cell counts of children r1 year old were used to simplify the age-related CD4+ cell count thresholds for prophylaxis. 3. Is it necessary to determine the infant's HIV status before starting PCP prophylaxis? No. All children born to HIV-infected mothers should be started on PCP prophylaxis at 4-6 weeks of age, regardless of the results of any diagnostic or immunologic testing. All HIV-exposed infants should be monitored to determine their HIV infection status--HIV culture and PCR are the preferred tests for such monitoring. 4. What is the earliest age at which prophylaxis should begin? Prophylaxis should begin at 4-6 weeks of age. PCP prophylaxis should not be given to children <4 weeks of age because their risk for PCP is low and because the use of sulfa drugs is not advised in this age group. If a newborn is receiving zidovudine (also referred to as ZDV or AZT) to prevent perinatal HIV transmission, prophylaxis should not be started until 6 weeks of age, when zidovudine used for this purpose is discontinued. 5. Once prophylaxis is started, how long should it continue? Prophylaxis should be stopped for any child found not to be infected with HIV. For the purpose of PCP prophylaxis, this can be determined as early as 4 months of age. Prophylaxis should be continued after 1 year of age for HIV-infected children who have had any CD4+ cell count <750 cells/fL or a CD4+ percentage <15% during the first year of life. HIV- infected children who are continued on PCP prophylaxis at 1 year of age should be evaluated again at 2 years of age. Prophylaxis should be continued after 2 years of age for children who have had any CD4+ cell count <500 cells/fL or a CD4+ percentage <15%. Continuation of prophylaxis should also be considered on a case-by-case basis for children with rapidly declining CD4+ cell counts or severe symptoms of HIV disease. 6. What medicine is recommended for preventing PCP in children? The medicine recommended for PCP prophylaxis is trimethoprim-sulfamethoxazole (also known as TMP-SMX, Bactrim~, Septra~, and Co-trimoxazole). This medicine has been shown to prevent PCP, is the same medicine recommended for preventing PCP in adults, and is approved by FDA for PCP prophylaxis. 7. Are there side effects from TMP-SMX? Most medicines have some side effects. There is extensive experience using TMP-SMX to treat common infections in children, such as ear infections and urinary tract infections. The most common side effects noted with TMP-SMX are mild rashes and upset stomach. Other side effects occur rarely, including low blood counts, liver and kidney problems, and more severe rashes. It is recommended that children receiving TMP-SMX have their blood count (CBC) measured monthly. 8. Are any other medicines recommended for PCP prophylaxis? TMP-SMX is the first choice for PCP prophylaxis. However, a small number of children will develop side effects to TMP- SMX that require stopping it. In this case, other medications are available for prophylaxis, including dapsone and aerosol pentamidine. 9. Which HIV-infected children are most at risk for PCP? PCP is most common among children 3-6 months old and among children with severe immunosuppression. 10. What are recommendations for monitoring CD4+ measurements of children? CD4+ cell counts and percentages should be measured in all HIV-exposed infants at 1 and 3 months of age. CD4+ monitoring is not necessary after HIV infection has been reasonably excluded. For infants who have been diagnosed as HIV-infected and for those whose infection status has not yet been determined, CD4+ values should be monitored at 6, 9, and 12 months of age and every 3-4 months thereafter. 11. For HIV-infected children r1 year old who are not receiving prophylaxis, when should PCP prophylaxis be started? HIV-infected children r1 year old may not be receiving prophylaxis because their HIV infection was only recently identified or because prophylaxis had been discontinued. Such children should start prophylaxis if their CD4+ values are in the range of the table below. Initiation of prophylaxis should also be considered on a case-by-case basis for children with rapidly declining CD4+ cell counts or severe symptoms of HIV disease. Age CD4+ Cell Count CD4+ Percentage 1-5 years <500 cells/fl <15% 6-12 years <200 cells/fl <15% 12. What impact do the revised PCP prophylaxis guidelines have on HIV screening of pregnant women? Infants born to HIV-infected women should be identified promptly so that prophylaxis can start before they are at risk for PCP. Diagnosing HIV infection among women before or during pregnancy is the most beneficial way to accomplish this goal because it not only allows for prompt initiation of PCP prophylaxis for HIV-exposed infants, but also gives women the opportunity to access interventions that could maintain or improve their own health and reduce the risk for transmitting HIV infection to their children through the use of zidovudine and avoidance of breastfeeding. Results from several areas with universal, routine HIV counseling and voluntary testing programs indicate that high test acceptance levels can be achieved without mandatory testing. The U.S. Public Health Service has drafted guidelines recommending counseling and voluntary HIV testing of all pregnant women as early during pregnancy as possible, and voluntary testing of infants if the mother's status is unknown. If these guidelines are followed, most HIV-exposed children will be identified in time to begin PCP prophylaxis before the age of highest risk for PCP. 13. Where can I get more information? The CDC National AIDS Hotline (1-800-342-2437) has trained information specialists to answer questions or provide referrals on HIV infection and AIDS. For single free copies of "1995 Revised Guidelines for Prophylaxis Against Pneumocystis carinii pneumonia for Children Infected with or Perinatally Exposed to Human Immunodeficiency Virus" or other printed material on HIV infection and AIDS, please call or write the CDC National AIDS Clearinghouse, P. O. Box 6003, Rockville MD 20850; telephone 1-800-458-5231.